Individual
SHANNON L WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP-BC, PMHNP-BC
Contact information
Practice address
1481 W 10TH ST, INDIANAPOLIS, IN 46202-2803
(317) 554-0000
Mailing address
12670 N RAINEY RD W, SYRACUSE, IN 46567-9784
(317) 753-6323
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
71001501
IN
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
71001501
IN
Other
Enumeration date
10/13/2006
Last updated
09/27/2022
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